MEDICARE: ANDREA BETH JACKSON LMFT-ASSOCIATE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	204092	TX

General Provider Information

NPI Number	:	1992472153
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREA BETH JACKSON LMFT-ASSOCIATE

Provider Business Mailing Address
First Line	:	5900 BALCONES DR STE 100
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78731-4298
Country	:	US
Telephone Number	:	512-318-2199
Fax Number	:

Provider Business Practice Location Address
First Line	:	8216 IRISH DR
Second Line	:
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76180-5530
Country	:	US
Telephone Number	:	817-307-8401
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2021
Last Update Date	:	08/25/2021

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